new york state application for certain ...otda.ny.gov/programs/applications/2921.pdfcitizenship...

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 1 CENTER/ OFFICE

APPLICATION DATE UNIT ID WORKER ID

CASE TYPE

SERV. IND

CASE NUMBER REGISTRY NUMBER VERS DISTRICT SUFFIX SNAP SUFFIX

CATEGORY LANG NUMBER REUSE INDICATOR

CASE NAME

EFFECTIVE DATE DISPOSITION SERVICES TRANSACTION TYPE

NEW OPENING REOPEN RECERTIFICATION

DENIAL REASON CODE WITHDRAWAL ELIGIBILITY DETERMINED BY (WORKER): DATE ELIGIBILITY APPROVED BY (SUPERVISOR): DATE SIGNATURE OF PERSON WHO OBTAINED ELIGIBILITY

INFORMATION DATE

FORM __________ 0F _____________ x DATE RECEIVED BY AGENCY

EMPLOYED BY: SOCIAL SERVICES DISTRICT PROVIDER AGENCY SPECIFY:

PA AUTHORIZATION PERIOD MA AUTHORIZATION PERIOD SNAP AUTHORIZATION PERIOD SERVICES AUTHORIZATION PERIOD

FROM TO FROM TO FROM TO FROM TO

NEW YORK STATE APPLICATION FOR CERTAIN BENEFITS AND SERVICES If you are blind or seriously visually impaired and need this application in an alternative

format, you may request one from your social services district. For additional information regarding the types of formats available and how you can request an application in an

alternative format, see the instruction book (PUB-1301 Statewide), available at www.otda.ny.gov or https://www.health.ny.gov/.

If you are blind or seriously visually impaired, would you like to receive written notices in an alternative format?

Yes No

If yes, check the type of format you would like: Large Print; Data CD; Audio CD; Braille, if you assert that none of the other

alternative formats will be equally effective for you.

If you require another accommodation, please contact your social services district. We are committed to assisting and supporting you in a professional and respectful manner. You are responsible for participating in activities, including work activities for Public Assistance and the Supplemental Nutrition Assistance Program, where required, so you can become self-sufficient. Whenever you see Public Assistance or PA on the application, it means Family Assistance and/or Safety Net Assistance. We call both programs Public Assistance. These PA programs are meant to assist you only until you can fully support yourself and your family. Please refer to the instruction book (PUB-1301 Statewide) and What You Should Know Books 1, 2 and 3 (LDSS-4148A, LDSS-4148B, and LDSS-4148C) when completing this application, and contact your social services district with any questions. When you see MA on the application, it means Medicaid. You may apply for MA using this application only if you are also applying for Public Assistance or the Supplemental Nutrition Assistance Program at the same time. If you wish to only apply for MA, you can go online at https://nystateofhealth.ny.gov/ and/or call 1-855-355-5777 for more information or to apply, or you may use the MA-only paper application - Form DOH-4220, which your worker can give you, or call MA help line at 1-800-541-2831. If you want to apply only for the Medicare Savings Program (MSP), you must apply with Form DOH-4328, which your worker can provide to you. If you have an immediate need for personal care services, you should apply for MA separately using the DOH- 4220 MA application form.

06 02 10

http://www.otda.ny.gov/https://www.health.ny.gov/

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 1

CHECK EACH PROGRAM YOU OR ANY HOUSEHOLD MEMBER ARE APPLYING FOR

Public Assistance (PA) Child Care in lieu of PA Supplemental Nutrition Assistance Program (SNAP) Medicaid (MA) and SNAP Medicaid (MA) and PA Services (S), including Foster Care (FC) Child Care Assistance (CC) Emergency Assistance Only (EMRG)

SECTION 2 SECTION 5 DO ANY OF THESE APPLY TO YOU?

Pregnant 1 Victim of Domestic Violence 2 Need To Establish Paternity 3 Need Child Support 4 Drug/Alcohol Problem 5 Fuel Or Utility Shutoff 6 No Place To Stay/Homeless 7 Fire Or Other Disaster 8 Have No Income 9 Serious Medical Problem 10 Pending Eviction 11 No Food 12 Need Foster Care 13 Need Child Care 14 Problems with English 15 Reasonable Accommodations 16

Other 17

WHAT IS YOUR PRIMARY

LANGUAGE?

ENGLISH OTHER (specify) ________

SPANISH

DO YOU WANT TO RECEIVE NOTICES IN:

ENGLISH ONLY ENGLISH AND SPANISH

SECTION 3 APPLICANT INFORMATION PLEASE PRINT CLEARLY FIRST NAME M.I. LAST NAME MARITAL

STATUS PHONE NUMBER ( ) AREA CODE

STREET ADDRESS APT. NO. CITY COUNTY STATE ZIP CODE

IN CARE OF NAME (COMPLETE IF YOU RECEIVE YOUR MAIL IN CARE OF ANOTHER PERSON)

MAILING ADDRESS (IF DIFFERENT FROM ABOVE) APT. NO. CITY COUNTY STATE ZIP CODE

HOW LONG HAVE YOU LIVED

AT YOUR PRESENT ADDRESS?

YEARS MONTHS IS THIS A SHELTER? YES NO

ANOTHER PHONE WHERE YOU

CAN BE REACHED

NAME PHONE NUMBER ( ) AREA CODE

DIRECTIONS TO CURRENT ADDRESS

FORMER ADDRESS APT. NO. CITY COUNTY STATE ZIP CODE

IF YOU ARE CURRENTLY WITHOUT A HOME, CHECK HERE

AGENCY HELPING APPLICANT/CONTACT PERSON PHONE NUMBER ( ) AREA CODE

DO YOU NEED THE MEDICAID PORTION OF THIS APPLICATION AND THE POTENTIAL RECEIPT OF ANY MEDICAID COVERAGE TO BE KEPT CONFIDENTIAL? YES NO

SECTION 4 If You Are Applying For SNAP: You can file an application the day you get it. In order to file a SNAP application, it must have, at minimum, your name, address (if you have one) and signature below. You must complete the application process, including signing the last page of the application and being interviewed. If eligible, you will get SNAP benefits back to the date you filed the application. You must be told, within 30 days of the date you turned in (filed) your application for SNAP benefits, if your application is approved or denied. If your household has little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources, you may be eligible to get SNAP benefits within five calendar days of the date you file. If you are a resident of an institution and are applying for both Supplemental Security Income (SSI) and SNAP benefits prior to leaving the institution, the filing date of the application is the date you leave the institution.

SNAP APPLICANT/REPRESENTATIVE SIGNATURE X

DATE SIGNED

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 3

DOES THIS PERSON (INCLUDING MINOR CHILDREN) BUY FOOD OR PREPARE MEALS WITH YOU?

HIGHEST SCHOOL GRADE COMPLETED

THIS PERSON IS APPLYING FOR: DATE OF BIRTH SEX

M OR F

RELATION- SHIP

TO YOU

SOCIAL SECURITY NUMBER OF APPLYING HOUSEHOLD MEMBERS

(See instruction book, PUB-1301 Statewide, or talk to your social

services district)

(Middle Initial)

RI LN FIRST NAME M.I. LAST NAME PA SNAP MA CC FC S EMR

G Month Day Year

YES NO

SELF

01

02

03

04

05

06

07

08

PLEASE LIST MAIDEN OR OTHER NAMES BY WHICH YOU OR ANYONE IN YOUR HOUSEHOLD HAVE BEEN KNOWN

Line No.

ONC FIRST NAME M.I. LAST NAME

Line No.

ONC FIRST NAME M.I. LAST NAME

IS ANYONE SANCTIONED?

YES NO IF YES, WHO REASON END DATE

NON-APPLICANT INFORMATION

LEGALLY

RESPONSIBLE

FOR

CONTRIBUTION/

CHECK IF MEMBER LN FIRST NAME LAST NAME YES NO WHOM? DEEMED INCOME OF SNAP HOUSEHOLD

NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS INFORMATION INDIVIDUAL EDUCATION CONSIDER NON-CITIZEN STATUS

STATUS ADJUSTED

DATE OF ENTRY/STATUS

APPLIED FOR CITIZENSHIP SPONSORED LN DEGREE RECEIVED LN DEGREE RECEIVED RCA/RMA REFERRAL

LN YES NO MONTH DAY YEAR YES NO YES NO 01 05

02 06

03 07

04 08

SECTION 6 HOUSEHOLD INFORMATION List everybody who lives with you, even if they are not applying with you. List yourself on the first line.

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16)

LN

SECTION 7 RACE/ETHNICITY Providing this information is voluntary. It will not affect the eligibility of the persons applying or the level of benefits received. The reason for requesting this information is to ensure that program benefits are distributed without regard to race, color, or national origin.

CLIENT IDENTIFICATION

NUMBER

ENTER APPROPRIATE CODES

H HISPANIC OR LATINO I NATIVE AMERICAN OR ALASKAN NATIVE A ASIAN B BLACK OR AFRICAN AMERICAN P NATIVE HAWAIIAN OR PACIFIC ISLANDER W WHITE U UNKNOWN (MA ONLY)

REL SSN SFUI MS SI LA EM CI EL

ENTER Y (YES) OR N (NO) FOR HISPANIC OR LATINO ENTER Y (YES) OR N (NO) FOR EACH RACE

H I A B P W U

01

02

03

04

05

06

07

08 ANTICIPATED FUTURE ACTION CASE TYPE RELATED CASE NUMBERS CONSIDER

LINE NO. CODE DATE Relationship

Filing Unit

Legally Responsible Relative

Single Economic Unit

SNAP Household Composition

SNAP Aged/Disabled Individual

Photo ID

AFIS (PA Only)

CBIC/PIN

RFI/OCA

Health Insurance

SERVICE ELIGIBILITY PROCESS CODE SFUI CODE SFUI CODE

SFUI CODE SFUI CODE

NEEDED REFERRALS COMPLETED

Legal

Services

SSA

NYSoH

Chronic Care/SSI-Related

MA-Only

Medicare Savings Program

REQUESTED DOCUMENTATION IN FILE

Photo ID

Birth Verification

Marriage License

Social Security Card

Code 9 Resolution

Immigration Status

Multi-Suffix/Co-op Case Notice (Single Economic Unit Questionnaire)

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 5 Please read this entire page carefully before completing it. If you have questions, see the instruction book (PUB-1301 Statewide) or talk to your social services district.

SECTION 8 CITIZENSHIP/NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS SECTION 9 CERTIFICATION LIST EVERYONE WHO IS APPLYING OR WHO IS REQUIRED TO APPLY.

You have to fill out Sections 8 and 9 if you are: Applying for Child Care Assistance only, but you need to fill out the information only for the

children who would be receiving Child Care Services. Applying for Foster Care only, but you need to fill out the information only for the children who

would be receiving Foster Care. Applying for other Services under certain circumstances.

Some social services programs require that you certify that you are a United States citizen, Native American or national of the U.S., or a non-citizen with satisfactory immigration status. Other programs do not. You MUST sign the Certification below only if you are a United States citizen, Native American or national of the United States, or a non-citizen with satisfactory immigration status, and you are applying for:

Public Assistance (where there are children in the household or a member of the household is pregnant), or

The Supplemental Nutrition Assistance Program, or Medicaid (except if the applicant is pregnant), or Child Care Assistance (certification is needed for the children only), or Foster Care (certification is needed for the children only), or Other Services under certain circumstances; Emergency Payment Assistance

An adult household member or authorized representative may sign for all household members. Example: A parent without a satisfactory non-citizen status may sign for his/her child with a satisfactory non-citizen status.


Systematic Alien Verification for Entitlements (SAVE)

An application for SNAP must list all persons living in the SNAP household. An application for PA must list all children for whom you are applying, their brothers and sisters, and all parents of those children who live together. If you do not check whether a listed person is a United States citizen, national of the U.S. or an non-citizen with a satisfactory immigration status, or provide an U.S. Citizenship and Immigration Services (USCIS) number (Alien Registration Number) or a non-citizen number (if applicable), that person will not be given assistance and the remaining members of the household will receive reduced benefits. If you are a Native American, check citizen/national.

SIGN* AND DATE THE BOX BELOW FOR EACH APPLICANT. In the case of an applying non-citizen with a satisfactory immigration status, check the program(s) for which each applying non-citizen has satisfactory immigration status. (See the instruction book, Pub-1301 Statewide.)

LN FIRST NAME MI LAST NAME Check either "CITIZEN / NATIONAL" or

"NON-CITIZEN" for each person.

USCIS NUMBER (ALIEN REGISTRATION NUMBER) OR NON-CITIZEN NUMBER

(If Applicable) CERTIFICATION DATE PA

S N A P

MA CC F C S

E M R G

01 CITIZEN/

NATIONAL

NON-CITIZEN A Sign Name

X

02 CITIZEN/

NATIONAL

NON-CITIZEN A

Sign Name

X

03 CITIZEN/

NATIONAL

NON-CITIZEN A

Sign Name

X

04 CITIZEN/

NATIONAL

NON-CITIZEN A

Sign Name

X

05 CITIZEN/

NATIONAL

NON-CITIZEN A

Sign Name

X

06 CITIZEN/

NATIONAL

NON-CITIZEN A

Sign Name

X

07 CITIZEN/

NATIONAL

NON-CITIZEN A

Sign Name

X

08 CITIZEN/

NATIONAL

NON-CITIZEN A Sign Name

X

By checking a box above and by signing the certification in Section 9, I hereby certify, under penalty of perjury, that I, and/or the person(s) for whom I am signing, am a United States citizen, Native American or national of the United States, or a non-citizen with satisfactory immigration status. I understand that signing this Certification may result in information about applying members of my household being submitted to the United States Citizenship and Immigration Services for verification of non-citizen status, if applicable. The use or disclosure of the information above is restricted to persons and organizations directly connected with the verification of citizenship status, and the administration or enforcement of the provisions of the Public Assistance, Supplemental Nutrition Assistance, Medicaid, Child Care Assistance, Foster Care and Services Programs.

A person who wishes to sign the Certification but cannot write may make an "X" on the line in front of a witness. The witness must sign below. I witnessed the marks made in lines: _____,______,_______,______,_____,_____ Signature of witness: _____________________________________ Date Signed: ____________________

*

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 10 INFORMATION REGARDING REFERRAL TO THE CHILD SUPPORT ENFORCEMENT UNIT

If you are applying only for child care assistance, you are not required to pursue child support and do not have to fill out this section. If you are applying for Medicaid in addition to Public Assistance or the Supplemental Nutrition Assistance Program, you may have to help us obtain medical support for yourself and your applying children. Answer the following questions to determine if you need to complete this section. Include yourself, as appropriate:

1. Are you applying for an individual under the age of 21 who was born out of wedlock and for whom paternity (legal fatherhood) has not been established? Yes No

2. Are you applying for an individual under the age of 21 who has an absent father or mother (noncustodial parent)? Yes No You do not need to complete this section if you answered No to both of these questions. Go to Section 11. You must complete this section if you answered Yes to either or both of these questions. Provide the names of all individuals under the age of 21 for whom you are applying and any information you currently have about those individuals noncustodial parents or putative (alleged) fathers. 3. Are you under the age of 21? Yes No If you answered Yes to this question, provide the information for your noncustodial parent(s) or putative father(s). As a condition of obtaining assistance, you are required to assign certain rights related to support, as described in the Notices, Assignments, Authorizations, and Consents section at the end of this application. You will be provided with the LDSS-4882 form, Information About Child Support Services and Application/Referral for Child Support Services, to complete and return to the Child Support Enforcement Unit. Except in situations of domestic violence or other good cause, as a condition of obtaining assistance you are required to cooperate with the Child Support Enforcement Unit to locate any noncustodial parent or putative father; establish paternity for each individual under the age of 21 born out of wedlock; and establish, modify, and/or enforce orders of support. You also will be provided with the LDSS-4279 form, Notice of Responsibilities and Rights for Support, which explains your responsibilities and your rights if you do not cooperate with the Child Support Enforcement Unit.

NAME OF INDIVIDUAL UNDER AGE 21

NONCUSTODIAL PARENT OR PUTATIVE FATHERS NAME AND ADDRESS

NONCUSTODIAL PARENT OR PUTATIVE FATHERS

DATE OF BIRTH

NONCUSTODIAL PARENT OR

PUTATIVE FATHERS SOCIAL SECURITY NUMBER

MONTH DAY YEAR A.

B.

C.

D.

E.

REQUESTED DOCUMENTATION IN FILE Acknowledgement of Paternity Child Support Order Good Cause Form (LDSS-4279) IV-D Attestation (LDSS-4281) Death Certificate Divorce Decree VA Benefits Order of Filiation/Paternity Birth Certificate

NEEDED REFERRALS COMPLETED CTHP CAP Application/Referral for Child

Support Services (LDSS-4882)

Paternity

CONSIDER Health Insurance of Non-

custodial Parent/Absent Spouse

Child Health Plus

TASA

Petition to Family Court SSI/SSA

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 7 SECTION 11 TAX FILING/DEPENDENT STATUS - Please select the tax status for each individual living in the household.

TAX STATUS

FIRST NAME MIDDLE INITIAL

LAST NAME SINGLE MARRIED FILING JOINTLY

MARRIED FILING SINGLE

HEAD OF HOUSEHOLD (WITH QUALIFYING INDIVIDUAL)

QUALFIYING WIDOW(ER) WITH DEPENDENT CHILD

DEPENDENT AND WILL BE FILING TAXES

WILL NOT BE FILING TAXES

Tax dependents not living in the household. Please list any tax dependents who do not live with you and are claimed by you or anyone in your household. If you do not file taxes, you can skip this question.

NAME OF TAX DEPENDENT NAME OF TAX FILER

FIRST NAME MIDDLE INITIAL LAST NAME FIRST NAME MIDDLE INITIAL LAST NAME

SECTION 12 ABSENT/DECEASED SPOUSE INFORMATION If the spouse of anyone applying lives someplace else or is deceased, please indicate below. NAME OF PERSON APPLYING NAME OF SPOUSE DATE OF SPOUSES BIRTH DATE OF SPOUSES DEATH,

IF APPLICABLE SPOUSES SOCIAL SECURITY NUMBER

SPOUSES ADDRESS, IF APPLICABLE CITY COUNTY STATE ZIP CODE

SECTION 13 ABSENT CHILD INFORMATION If anyone applying has a child under the age of 21 living someplace else, please indicate below.

NAME OF PERSON APPLYING

NAME OF ABSENT CHILD

DATE OF BIRTH ADDRESS OF CHILD (STREET, CITY,

COUNTY, STATE, AND ZIP CODE) PATERNITY ESTABLISHED?

DO YOU PAY CHILD SUPPORT?

Yes No Yes No

SECTION 14 TEEN PARENT INFORMATION TEEN PARENT TEEN PARENT CHILDREN

Is there a parent under the age of 18 (teen parent) in the household? Yes No

Name ________________________________________________

LN NO. __________________ LN NO. _____________________

Does the teen parents child live in the household? Yes No

Name of teen parents child _______________________________________________

LN NO. Marital Status

High School Diploma/High School Equivalent?

LN NO. Marital Status

High School Diploma/High School Equivalent?

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 15 INCOME INFORMATION: Indicate if you or anyone who lives with you receives money from: YES NO WHO AMOUNT/VALUE &

FREQUENCY WHO AMOUNT/VALUE &

FREQUENCY CD INCOME

Unemployment Insurance Benefits 1 49 LN No.

SOURCE CODE AMOUNT PERIOD

Supplemental Security Income (SSI) Benefits (State and Federal Total) 2

45

Social Security Disability (SSD) Benefits 3 42

Social Security Dependent Benefits 4

Social Security Survivors Benefits 5 43 Social Security Retirement Benefits 6 44

Railroad Retirement Benefits 7 38 Retirement Benefits (Pensions) 8 39 Dividends/Interest from Stocks, Bonds, Savings, etc. 9 03

Workers Compensation 10 59 NYS Disability Benefits 11 33 Veterans Pension/Benefits/Aid and Attendance 12 55 Public Assistance Grant 13 37 GI Dependency Allotments 14 10

Education Grants or Loans 15 Contributions/Gifts (Received) 16 Foster Care Payments (Received) 17

Child Support Payments (Received) Received From:________________________________________ 18

06

Spousal Support (Received) 19 02

Private Disability Insurance - Health/Accident Insurance Policy Income 20

No-Fault Insurance Benefits 21 50 Union Benefits (including Strike Benefits) 22 Loans, Other than Education (Received) 23 Income from a Trust (including income you are currently entitled to receive, or were entitled to receive in the past, that has not been distributed) 24

Training Allotments/Stipends 25 31

Rental Income (Received) 26 14

Boarders/Lodgers Income (Received) 27

Other Income

(Please Specify)

CONSIDER Child Support Disregard/Pass-Through

Explained Budgeted SNAP Aged/Disabled Indicator

Disability Review

Reception and Placement Grant (SNAP Only)

Refugee Matching Grant

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 9 Deductions: Certain types of Medicaid budgeting allow applicants/recipients to reduce their countable income with deductions that they take on their federal taxes. These are specific expenses that the Internal Revenue Service (IRS) allows people to deduct to reduce their taxable income. Only record deductions here if you will claim them on the current years tax return.

YES NO WHO AMOUNT/VALUE & FREQUENCY WHO AMOUNT/VALUE &

FREQUENCY

Educator expenses 1

Individual Retirement Account (IRA) deduction 2

Student loan interest deduction 3

Tuition and fees 4

Certain business expenses (reservists, artists, fee-based government officials) 5

Health savings account deduction 6

Job-related moving expenses 7

Deductible part of self-employment (S/E) tax 8

S/E, SIMPLE & qualified plans 9

S/E health insurance deduction 10

Penalty on early withdrawal of savings 11

Alimony paid 12

Domestic production activities deduction 13

Additional adjustments added on line 36 (IRS Form 1040 only) 14

Archer MSA deduction 15

Other Adjustment (Please Specify)

SECTION 16 STEP-PARENT/NON-CITIZEN WITH SATISFACTORY IMMIGRATION STATUS SPONSOR INFORMATION

Answer all questions listed below.

Does the step-parent of any children who live with you have any resources or receive income of any kind?

YES NO WHO? NEEDED REFERRAL COMPLETED

UIB

Is anyone in your household a non-citizen with satisfactory immigration status who was sponsored for admission into the U.S.?

NAME OF SPONSOR: PHONE NO.: ADDRESS:

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 17 EMPLOYMENT INFORMATION

I am currently: employed self-employed unemployed

Gross Income $ ________________ (Include wages, salary, overtime pay, commissions, and tips)

Hours Worked Monthly _________________

Paid: Weekly Bi-Weekly Monthly Day of the week paid: Employers Name and Address: 1

______________________________________________ Phone No. __________________

______________________________________________

Is anyone else who lives with you currently: employed self-employed

Who: _________________________________________________

Gross Income $ ________________ Hours Worked Monthly _________________ Paid: Weekly Bi-Weekly Monthly Day of the week paid: 2 Employers Name and Address:

______________________________________________ Phone No. __________________

______________________________________________

Is health insurance available through your employer? Yes No

Does anyone who lives with you have health insurance with an employer? Yes No

Who: _________________________________________ 3

Name of Insurance Company: _________________________________________________________

Do you or anyone who lives with you have a child or dependent care expenses due to employment?

Yes No

Who: _________________________________________ 4

Do you or anyone who lives with you have other employment-related expenses?

Yes No

Who: _________________________________________ 5


CINTRAK/RFI/IRCS

1099

Employment Verification

Income Tax Return

Self-Employment Worksheet

Wage Stubs

Work Registration Form

Dependent/Child Care Form/Statement

Approval of Informal Child Care Provider

CONSIDER

Limited English Proficiency Earned Income Tax Credit (see PUB-4786) Explaining Periodic Reporting Requirements Net Loss of Cash Income P.A.S.S. Income Amount and Sources Employment Sanctions Temporary Employment Disability Review Individual Development Account (IDA) Voluntary Quit


CAP

Disability

Employment

TPHI/COBRA

UIB

Workers Compensation

Drug/Alcohol

Domestic Violence

Refugee Cash Assistance

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 11 If not employed, when was the last time you or anyone who lives with you worked?

Who: _________________________________________ When: __________________________

Where: __________________________________________________________________________ 6

Why did you (or they) stop working? ___________________________________________________

Did you or anyone living with you file for unemployment? Yes No

If yes, who? _______________________ When?: ________________

Status of filing: Approved Denied Pending

Are you or is anyone who lives with you participating in a strike? Yes No Who: _________________________________________ When the strike began: ___________________________

7

Are you or is anyone who lives with you a migrant or seasonal farm worker?

Yes No

Who: _________________________________________ 8

Do you or any other adult who lives with you have any medical conditions that limit the ability to work or the type of work that can be performed? Yes No

Who: ____________________________________

Describe Limitations: _____________________________________________________________

_____________________________________________________________

9

Could you accept a job today? Yes No 10

If not, why? ________________________________________________________________________

What type of work would you like to do? _________________________________________

_________________________________________________________________________________ 11

CHILD/DEPENDENT CARE EXPENSES

Who Pays Amount Name Age Care Provider

$

$

$

$

$

$

$

$

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 18 EDUCATION/TRAINING What is your highest level of education completed? __ Less than high school diploma If so, last grade completed? ______ __ Completion of an Individualized Education Plan (IEP) __ High school diploma or General Equivalency Diploma (GED) or Test Assessing

Secondary Completion (TASC) 1 __ Associates Degree (2-year college degree) __ Bachelors Degree (4-year college degree) or higher

Does anyone else in the household have a high school diploma, General Equivalency Diploma (GED) or Test Assessing Secondary Completion (TASC), or higher level of education?

If yes, who: _______________

Degree attained:_________________

Date completed: _________________

Yes No

2

Indicate if you or anyone who lives with you who is applying for or getting assistance:

Is or has been in any training program? Yes No

Who

Where 3

Program

Dates attended ________________________________

Dates completed _______________________________

Is 16 years of age or older and is attending school or college?

Yes No

Who 4

Where

Is under 16 years of age and is attending school? Yes No

Who

School

Who

School

Who

School 5

Who

School


School Attendance Verification (LDSS-3708)

Educational Grant Worksheet

Child Care Statement


Supportive Services

CONSIDER YES NO Does anyone 18 through 49 who is attending college half-time or more

meet the SNAP student eligibility requirement?

Does anyone pay for child or dependent care to attend school or training?

Is there a 16-19 year-old parent who does not have a high school or equivalency diploma and who is not attending school?

Is anyone in training?

Are any other supportive services appropriate?

Are there any training related expenses?

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 13 SECTION 19 RESOURCES INFORMATION Indicate if you or anyone who lives with you who is applying: YES NO WHO AMOUNT/VALUE WHO AMOUNT/VALUE NEEDED REFERRAL COMPLETED

Has cash available 1 Legal

Has a checking account(s) 2 Resource

Has a savings account(s) or certificate(s) of deposit 3

Has a credit union account(s) 4

Has life insurance 5

Has title or registration to a motor vehicle(s) or other vehicle(s): Year ________ Make/Model ____________________________ Year ________ Make/Model ____________________________

Other______________________________________________ 6

Has stocks, bonds, certificates or mutual funds 7

Has savings bonds 8 Has an IRA, Keogh, 401(k) or deferred compensation account(s) 9 Has an irrevocable burial trust 10 Has a burial fund 11

Has a burial space 12

Has his/her own home 13

Has real estate, including income-producing and non-income-producing property 14

Is eligible for an income tax refund 15

Has an annuity 16

Is the beneficiary of a trust 17 Expects to receive a trust fund, lawsuit settlement, inheritance or income from any other sources 18

Has an in trust account(s) 19

Has a safe deposit box(es) 20

Has resources other than those listed above 21

Has anyone (including your spouse, even if not applying or living with you) given away any cash, or sold/transferred any real estate, income or personal property in the past 36 months? 22

Has anyone (including your spouse, even if not applying or living with you) ever created a trust in the past or transferred any assets to a trust within the past 60 months? If yes, when? _______________________________________ 23

VEHICLE INFORMATION

YR. MAKE MODEL OWNERS NAME AMOUNT OWED NADA VALUE EXEMPT LIEN HOLDER ACCOUNT NO. YES* NO $ $ $ $ *IF EXEMPT, WHY?

LIFE INSURANCE FACE AMOUNT CASH VALUE


Resource Checklist

Market Value

DMV Clearance

Bank Statement

Assignment of Proceeds

Car/Vehicle Title

Car/Vehicle Registration (Older Models)

Bank Clearance

RFI/OCA

1099

CONSIDER

Childrens Resources Lump Sum Boats, Campers, Snowmobiles Individual Development Account (IDA) Exempt Vehicles

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 20 MEDICAL INFORMATION

Indicate if you or anyone who lives with you who is applying: YES NO IF YES, WHO

Has any medical bills or medically-related expenses 1

Is on Medicaid with a spend-down 2

Has health or hospital/accident insurance (including insurance from employer) 3

POLICY NO.: AMOUNT: FREQUENCY OF PAYMENT:

Has health insurance available through an employer 4 INSURANCE COMPANY NAME:

Has Medicare (red, white, and blue card) 5 WHO IS COVERED:

Has a health attendant/home health aide 6 EFFECTIVE DATE:

Is blind, sick or disabled 7 Is the answer to question 7 in this section consistent with Section 17 asking if the applicant or any other adult who lives in the household have any medical conditions that limit their ability to work or the type of work that they can perform?

Is a child with a developmental disability 8

Is in a hospital, nursing home or other medical institution 9

Has paid or unpaid medical bills within 3 months preceding the month of this application 10

Is or was drug or alcohol dependent 11 Needs home care/personal care 12 Is on SSI or has ever applied for SSI 13 Is pregnant If pregnant, due date: _____________________________ 14 Expected number of births: _________________________

Receives treatment from a drug abuse or alcohol treatment program 15

Has not been able to work for at least 12 months because of a disability or illness 16

Has daily activity limited because of a disability or illness that has lasted or will last at least 12 months 17

Has been in a car accident or work-related accident in the past two years 18

Has had a government agency (public program) besides Medicaid or Medicare pay any of your medical bills If yes, what agency _____________________ 19

Will billing any other health insurance cause harm to your physical or emotional health or safety, and/or will it interfere with the privacy and confidentiality of your application for or receipt of Medicaid? 20


Pregnancy Statement

Med/Psych Statement

Drug/Alcohol Screening (LDSS-4571)

Drug/Alcohol Statement

Paid or Unpaid Medical Bills

SSI Application Verification (PA ONLY) CONSIDER

AD/SSI Related SNAP Aged/Disabled Indicator SNAP Medical Deduction TPHI Reimbursement Buy-In Eligibility Kreiger (LDSS-3664) Domestic Violence SSI Referral Earned Income Credit NEEDED REFERRALS COMPLETED

SSI (D-CAP) Disability Interview (LDSS-1151) Medical Report (LDSS-486, 486t) Disability Report AD TPHI ACCES-VR CTHP Family Planning SSA (RSDI) Veterans Benefits Veterans Counseling Child Health Plus COBRA Eligibility Nurses Aide Service Home Care NYSoH MA-Only (DOH-4220) SSI-Related/Chronic Care

(DOH-4220 with Supplement A)

LDSS-4526 or local equivalent

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 15 RETROACTIVE

MEDICAID WHO DATE

RECURRING MEDICAL

EXPENSES

WHO AMOUNT $

MEDICAL BILLS: YES NO TPHI: YES NO

HEALTH PLAN SELECTION Most people enrolled in Medicaid are required to join a managed care health plan unless they are in an exempt category. Use this section to choose a health plan. If you do not know what health plans are available, ask your worker or call 1-800-505-5678.

Name of Plan You Are Enrolling In

Last Name First Name Date Of Birth mm/dd/yy

Sex M/F

ID# (from Medicaid Card if you have one)

Social Security # (optional if pregnant)

Primary Care Provider (PCP) or Health

Center (check box if current provider)

Name and ID# of OB/GYN (check box if current provider)

SECTION 21 SHELTER REQUESTED DOCUMENTATION IN FILE

Landlord Statement

Rent Receipt

Tenant of Record

Customer of Record

Voluntary Restrict

Mandatory Restrict

Subsidized Housing

Mortgage/Title Search Section 8 Lease or Statement from

Section 8 Office

Property Lien

Shelter/Utility Repayment Agreement CONSIDER

Utility and/or Fuel Restrict Utility Guarantee HEAP Subsidized Housing May Show Total Rent, NOT Client Amount Foster Care-Related Additional Allowances SNAP Household Composition Rules SNAP Aged/Disabled Indicator Real Property Tax Credit AIDS/HIV Emergency Shelter Allowance Property Lien If Shelter Expenses/Living Quarters Are Shared by More than

One Household

WHAT IS YOUR LANDLORDS NAME?

______________________________________________________________________

WHAT IS YOUR LANDLORDS ADDRESS?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

WHAT IS YOUR LANDLORDS PHONE NUMBER?

( ) _________________________________________________________

YES NO IF YES, AMOUNT

Do you or anyone who lives with you have a rent, mortgage or other shelter expense?

$

Do you or anyone who lives with you have a heat bill separate from your rent or other shelter expense?

$

SHELTER COSTS

MONTHLY ACTUAL COST

A. Room and Board

B. Rent

C. Trailer Lot Rent

D. Mortgage Payment

1. Principal

2. Interest 3. Property Tax

(including School Tax)

4. Homeowners Insurance (incl. Fire Insurance)

5. Taxes Included in Mortgage (Escrow Payment)

6. Assessments (Sewer, etc.)

E. Total Mortgage Payment (Line 1-6)

TOTAL (Lines A - E)

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) SECTION 21 SHELTER (CONT.)

Do you or anyone who lives with you have the following expenses separate from your rent or other shelter expense?

YES NO IF YES, AMOUNT

Electricity (for needs other than heat; example: lights, cooking, hot water, etc.) 1

$

Natural Gas (for needs other than heat; example: cooking, hot water, etc.) 2

$

Water 3 $

Air Conditioning 4 $

Propane (for needs other than heat) 5 $

Sewer 6 $

Trash 7 $

Other Utilities and Expenses 8

Specify __________________

$

Do you live in public housing? 9

Do you live in Section 8, HUD, or other subsidized housing? 10

Do you live in a drug/alcohol treatment facility? 11

*Check Primary Heat Type: Natural Gas Oil PSC Electric Coal Other ________________________ Kerosene Propane Municipal Electric Wood

ADDITIONAL INFORMATION SECTION 22 OTHER EXPENSES

Indicate if you or anyone who lives with you who is applying: YES NO IF YES, AMOUNT HOW OFTEN PAID LEGALLY

OBLIGATED CHILD IN SNAP HH

Pays child support 1 $ YES NO YES NO Pays spousal support 2 $ Pays for child care 3 $ Pays for dependent care 4 $

Pays tuition, fees, or other educational expenses 5 $

Has additional expenses (Example: car payment, car insurance payment, credit card payments, other loan payments, etc.) Specify: _______________________________ 6

$

Do you or anyone who lives with you who is applying owe at least four months of support for a child under the age of 21? 7

YES NO

MONTHLY EXPENSES

MONTHLY ACTUAL COST

NAME OF DEALER

ACCOUNT NUMBER

IN WHOSE NAME IS THE BILL?

(CUSTOMER OF RECORD)

WHO IS THE TENANT OF RECORD?

A. Heat*

B. Electricity (for cooking, lights, hot water)

C. Gas (for cooking, hot water)

D. Liquid Propane Gas

E. Other Utilities or Expenses

F. Air Conditioning

G. Utility Installation Fees

H. Sewer

I. Trash

J. Water

LDSS-2921 Statewide (Rev. 7/16) DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION PAGE 17 SECTION 23 OTHER INFORMATION

Do you buy or plan to buy meals from a home delivery or communal dining service? 8

YES NO

Are you able to cook or prepare meals at home? 9 YES NO VETERAN STATUS VETERAN CODE

Have you or anyone in your household ever been in the U.S. military? Who? ________________________________________ 10

YES NO

Has your spouse ever been in the U.S. military? 11 YES NO

Is anyone in your household a dependent of someone who is or was in the U.S. military? Who? ________________________________________ 12

YES NO

Do you or does anyone who lives with you receive assistance or services now? YES NO 13 IF YES, WHO TYPE OF ASSISTANCE LOCATION RECEIVED DATES RECEIVED

Have you or anyone who lives with you received assistance or services in the past? YES NO 14

IF YES, WHO (Please list all previous names)

TYPE OF ASSISTANCE LOCATION RECEIVED DATES RECEIVED

NEEDED REFERRALS COMPLETED CONSIDER

Services SNAP Dependent Care Deductions

UIB

OTHER INFORMATION (CONT.) YES NO WHO

Have you or anyone who lives with you who is applying moved into this county from another New York State county within the past two months?

Have you or anyone who lives with you ever been found guilty of and/or been disqualified for Public Assistance and/or the Supplemental Nutrition Assistance Program (SNAP) because of fraud/an Intentional Program Violation?

Have you or anyone who lives with you received benefits for which they were not entitled, which have not been fully repaid to this or another agency?

Have you or any member of your household been convicted of making a fraudulent statement or representation of residence in order to receive Public Assistance in two or more states?

Have you or any member of your household been convicted of fraudulently receiving duplicate SNAP Benefits in any state after September 22, 1996?

Have you or any member of your household been convicted of buying or selling SNAP Benefits for a combined amount of over $500 or more after September 22, 1996?

Have you or any member of your household been convicted of trading SNAP benefits for firearms, ammunition or explosives, or drugs?

Are you or any member of your household fleeing to avoid prosecution, custody or confinement after conviction of a felony or attempted felony and actively being pursued by law enforcement?

Are you or any member of your household violating probation or parole according to a court order?

PROPERTY TRANSFER STATUS I have I have not sold, transferred or given away any of my property to

anyone to get Public Assistance or SNAP Benefits.


Educational Grant Worksheet

Child/Dependent Care Statement

Recoupments

Outstanding Overpayment

Pending Disqualification

DO NOT WRITE IN THE SHADED AREAS OF THIS APPLICATION LDSS-2921 Statewide (Rev. 7/16) IF TOTAL EXPENSES (INCLUDING EXPENSES NOT USED IN THE BUDGET DETERMINATION) EXCEED INCOME (INCLUDING PA GRANT), EXPLORE HOW THE HOUSEHOLD IS MEETING ITS OBLIGATIONS.

EMERGENCY CASH ASSISTANCE Is there an immediate need? If not, why not?

Actual Expenses

$

- Actual Income

$

= Difference

$

YES NO Does Client Receive

Contribution Towards Difference

If Yes, From Whom?

________________________________

NOTES/COMMENTS

CONSIDER

Actual Expenses, including: shelter, fuel/utility costs, telephone costs, etc.

Actual Shelter

Actual Fuel/Utility Costs

Telephone Expenses

Car Expenses

Furniture/Appliance Rental

Cable TV

Tuition

Out-of-Pocket Medical Expenses

LDSS-2921 Statewide (Rev. 7/16) PAGE 19

NOTICES, ASSIGNMENTS, AUTHORIZATIONS, and CONSENTS COLLECTION AND USE OF SOCIAL SECURITY NUMBERS The collection of Social Security Numbers (SSNs) is authorized for each household member with respect to the Supplemental Nutrition Assistance Program (SNAP), pursuant to the Food and Nutrition Act of 2008 (as amended). Anyone applying for SNAP must provide an SSN in order to receive benefits. If you or anyone applying does not have an SSN, that person must apply for an SSN with the Social Security Administration (visit www.SSA.gov or call 1-800-772-1213). With respect to all other programs for which this application form requires an SSN, the collection of SSNs is also mandatory and is authorized under one or more of the following sections of law: Section 205(c) of the Social Security Act (42 U.S. Code 405), Section 1137 of the Social Security Act (42 U.S. Code 1320b-7) and Section 7(a)(2) of the Privacy Act of 1974. See the instruction book (PUB-1301 Statewide) or talk to your social services district if you have questions. The information we collect will be used to determine whether your household is eligible or continues to be eligible for assistance or benefits. The information will be used to check identity, to verify earned and unearned income, to determine if absent parents can receive health insurance coverage for applicants or recipients, to determine if applicants or recipients can obtain child or spousal support, and to determine if applicants or recipients can receive money or other help. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. Besides using the information you give us in this way, the state will use the information to prepare statistics about all of the people receiving benefits from the Home Energy Assistance Program (HEAP) (see below). This information may be disclosed to other state and federal agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. Information collected with respect to applicants for and recipients of Family Assistance and Safety Net Assistance, including SSNs, may be used to assist in the formation of jury pools. If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to federal and state agencies, as well as private claims collection agencies, for claims collection action. SSNs of ineligible household members will also be used and disclosed in the manner above. Besides using the information you give us in this way, the State also uses the information to prepare statistics about all the people receiving benefits from HEAP. The information is used for quality control by the State to make sure social services districts are doing the best job they can. It is used to verify your energy supplier and to make certain payments to such vendors.

NONDISCRIMINATION NOTICE This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and, in some cases, religion or political beliefs. The United States Department of Agriculture (USDA) also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a Supplemental Nutrition Assistance Program (SNAP) complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410

(2) Fax: (202) 690-7442; or

LDSS-2921 Statewide (Rev. 7/16)

(3) Email: [email protected].

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish, or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm. To file a complaint of discrimination regarding a program receiving federal financial assistance through the U.S. Department of Health and Human Services (HHS), write HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call (202) 619-0403 (voice) or (800) 537-7697 (TTY). This institution is an equal opportunity provider.

CONSENT FOR INVESTIGATION I agree to any investigation to verify or confirm the information I have given in connection with my request for Public Assistance (PA), Medicaid, Supplemental Nutrition Assistance Program (SNAP) Benefits, Home Energy Assistance Program Benefits, Services or Child Care Assistance. If additional information is requested, I will provide it. I will also cooperate fully with state and federal personnel in any PA and/or SNAP Quality Control Review. If I am applying for SNAP, I understand that the social services district will request and use information available through the Income and Eligibility Verification System to investigate my application, and may verify this information through collateral contacts if discrepancies are found. I also understand that such information may affect my eligibility for SNAP and/or the level of SNAP Benefits I receive.

CONSENT FOR RELEASE OF CONFIDENTIAL UNEMPLOYMENT INSURANCE INFORMATION I authorize the New York State Department of Labor (DOL) to release any confidential information maintained by DOL for Unemployment Insurance (UI) purposes to the New York State Office of Temporary and Disability Assistance (OTDA). This information includes UI benefit claims and wage records. I understand that OTDA, along with state and local agency employees working in social services district offices, will use the UI information for establishing or verifying eligibility for, and the amount of, Public Assistance, Medicaid, Supplemental Nutrition Assistance Program Benefits, Home Energy Assistance Program Benefits or Child Care Assistance, applied for in this application and for investigations to determine whether I received benefits to which I was not entitled. OTDA may also share the information with the New York State Office of Children and Family Services (OCFS) and the New York State Department of Health (DOH). OCFS will use the information to monitor the Child Care Assistance program.

RELEASE OF INFORMATION TO SERVICE PROVIDERS I give permission to the social services district and New York State to share information regarding Public Assistance or Supplemental Nutrition Assistance Program benefits that I or any member of my household for whom I can legally give authorization have received, for purposes of verifying my eligibility for services and payment related to program administration provided by a State or local contractor. Such services may include, but are not limited to, job placement or training services provided to help me or members of my household obtain and retain employment.

CHANGE REPORTING I agree to inform the agency promptly of any change in my address, needs, income, and property, able-bodied adult without dependents (ABAWD) status, pregnancy status or living arrangements, to the best of my knowledge or belief. If I am applying for Child Care Assistance, I agree to inform the agency immediately of any change in family income, who lives in my home, employment, child care arrangements or other changes which may affect my continued eligibility or amount of my benefit.

PENALTIES Federal and state laws provide for penalties of fine, imprisonment or both if you do not tell the truth when you apply for Public Assistance, Medicaid, Supplemental Nutrition Assistance Program, Services or Child Care Assistance (Assistance, Benefits or Services) or at any time when you are questioned about your eligibility, or cause someone else not to tell the truth regarding your application or your continuing eligibility. Penalties also apply if you conceal or fail to disclose facts regarding your initial and continuing eligibility


for Assistance, Benefits or Services, or if you conceal or fail to disclose facts that would affect the right of someone for whom you have applied to obtain or continue to receive Assistance, Benefits or Services. If you are an authorized representative, such Assistance, Benefits or Services must be used for the other person and not for yourself. Federal and state laws provide that any transfer of assets for less than fair market value made by an individual or an individuals spouse, within 60 months prior to the first of the month in which the individual is both in receipt of nursing facility services and has submitted an application for Medicaid, may render the individual ineligible for nursing facility services or home and community-based waivered services for a period of time. It is unlawful to obtain Assistance, Benefits or Services by concealing information or providing false information.

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM DISQUALIFICATION PENALTIES Any information you provide in connection with your application for the Supplemental Nutrition Assistance Program (SNAP) will be subject to verification by federal, state and local officials. If any information is incorrect, you may be denied SNAP Benefits. You may be subject to criminal prosecution if you knowingly provide incorrect information which affects eligibility or the amount of benefits. Any person convicted of a felony for knowingly using, transferring, acquiring, altering or possessing SNAP authorization cards or access devices may be fined up to $250,000, imprisoned up to 20 years or both. The individual may also be subject to prosecution under the applicable federal and state laws. Anyone who is violating a condition of probation or parole, or anyone who is fleeing to avoid prosecution, custody or confinement of a felony and is actively being pursued by law enforcement, is not eligible to receive SNAP Benefits. You may be found ineligible for SNAP or found to have committed an Intentional Program Violation (IPV) if you make a false or misleading statement, or misrepresent, conceal or withhold facts, in order to qualify for benefits or receive more benefits; purchase a product with SNAP benefits with the intent of obtaining cash by intentionally discarding the product and returning the container for the deposit amount; or commit or attempt to commit any act that constitutes a violation of federal or state law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking SNAP Benefits, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system. Additionally, the following is not allowed and you may be disqualified from receiving SNAP Benefits and/or be subject to penalties for actions that include: Using SNAP benefits to buy non-food items, such as alcohol or cigarettes; Using SNAP benefits to pay for food previously purchased on credit; Allowing someone else to use your EBT card in exchange for cash, firearms, ammunition or explosives, or drugs, or to purchase food for individuals who are not members of your

SNAP household; or Using or having in your possession EBT cards that do not belong to you, without the card owners consent.

Individuals found to have committed an IPV either through an administrative disqualification hearing or by a federal, State or local court, or have signed either a waiver of right to an administrative disqualification hearing or a disqualification consent agreement in cases referred for prosecution shall be ineligible to participate in SNAP for a period of: 12 months for the first SNAP IPV; 24 months for the second SNAP IPV; 24 months for the first SNAP IPV that is based on a court finding that the individual used or received SNAP Benefits in a transaction involving the sale of a controlled substance

(illegal drugs or certain drugs for which a doctors prescription is required); or 120 months if the individual is found to have made a fraudulent statement about who he/she is or where he/she lives in order to get multiple SNAP Benefits simultaneously, unless

permanently disqualified for a third SNAP IPV. Additionally, a court may bar an individual from participating in SNAP for an additional 18 months.

An individual can be permanently disqualified from receiving SNAP Benefits for: The first SNAP IPV based on a court finding that the individual used or received SNAP Benefits in a transaction involving the sale of firearms, ammunition or explosives; The first SNAP IPV based on a court conviction for trafficking SNAP Benefits for a combined amount of $500 or more (trafficking includes the illegal use, transfer, acquisition,

alteration or possession of SNAP authorization cards or access devices); The second SNAP IPV based on a court finding that the individual used or received SNAP Benefits in a transaction involving the sale of a controlled substance (illegal drugs or

certain drugs for which a doctors prescription is required); or A third SNAP IPV.

REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSES Your household must report child care and utility expenses in order to get a Supplemental Nutrition Assistance Program (SNAP) deduction for these expenses. Your household must report and verify rent/mortgage payments, property taxes, insurance, medical expenses and child support paid to a non-household member in order to get a SNAP deduction for these expenses. Failure to report/verify the above expenses will be seen as a statement by your household that you do not want to receive a deduction for these unreported/unverified expenses. A deduction for these expenses may make you eligible for SNAP or may increase your SNAP benefits. You may report/verify these expenses at any time in the future. The deduction would then be applied to the calculation of SNAP benefits in future months, in accordance with the rules for change reporting (see Change Reporting, above).


SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM AUTHORIZED REPRESENTATIVE You can authorize someone who knows your household circumstances to apply for Supplemental Nutrition Assistance Program (SNAP) Benefits for you. You can also authorize someone outside your household to get SNAP Benefits for you or to use them to buy food for you. If you would like to authorize someone, you must do so in writing. You may authorize someone by printing the persons name, address, and phone number immediately below, and having them sign in the signature section at the end of this application. When an Authorized Representative is applying on behalf of a SNAP household that does not reside in an institution, both the Authorized Representative and a responsible adult member of the household must sign and date the signature section at the end of this application, unless the SNAP household has otherwise designated the Authorized Representative to do so in writing. NAME, ADDRESS AND PHONE NUMBER OF AUTHORIZED REPRESENTATIVE (PLEASE PRINT):

STANDARD UTILITY ALLOWANCE I understand that Public Assistance and Supplemental Nutrition Assistance Program (SNAP) recipients are categorically income eligible for the Home Energy Assistance Program (HEAP). I also understand that if I have not received a HEAP benefit of greater than $20 in the current month or previous 12 months, or a similar energy assistance benefit, I must pay for heating or air conditioning separately from my rent in order to receive the heating/cooling standard utility allowance (i.e., a deduction) for SNAP. I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to the New York State Office of Temporary and Disability Assistance, the local social services district and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program performance measurement.

RELEASE OF MEDICAL INFORMATION I consent to the release of any medical information about me and any members of my family for whom I can give consent by my primary care provider, any other health care provider or the New York State Department of Health (DOH) to my health plan and any health care providers involved in caring for me or my family, as reasonably necessary for my health plan or my providers to carry out treatment, payment, or health care operations; by my health plan and any health care providers to DOH and other authorized federal, state, and local agencies for purposes of administration of Medicaid; and, by my health plan to other persons or organizations, as reasonably necessary for my health plan to carry out treatment, payment, or health care operations. I authorize the release of any health-related information about me and any members of my family for whom I can legally give authorization related to the provision of assistance and services and my ability to participate in work activities, including employment, to the New York State Office of Temporary and Disability Assistance (OTDA), the New York State Office of Children and Family Services or the local social services district, as reasonably necessary for the provision of Public Assistance benefits; for services, including child welfare services; for determining appropriate work activity assignments; for determining the need to apply and for making application for Supplemental Security Income Benefits; for establishing appropriate treatment plans for restoring employability; and for determining eligibility for exemptions from the State sixty-month time limit on cash assistance receipt. If I am required to apply for benefits administered by the Social Security Administration, the information specified above may be shared with the Social Security Administration. I also agree that the information released may include HIV, mental health or alcohol and substance abuse information about me and members of my family, to the extent permitted by law, unless a box is checked below. If more than one adult in the family is joining a Medicaid health plan, the signature of each adult applying is necessary for consent to release information. I understand that my ability to consent to the release of information relating to any minor children for whom I may give consent is limited by the extent to which I can obtain information regarding treatment, diagnosis and procedures on their behalf. _______ Do not disclose HIV/AIDS information ______ Do not disclose drug and alcohol information _______ Do not disclose mental health information


RELEASE OF EDUCATIONAL RECORDS I give permission to the New York State Department of Health and the social services district to:1) obtain any information regarding the educational records of myself and/or my minor child(ren), herein named, including information necessary for claiming Medicaid reimbursement for health-related educational services; and 2) provide the appropriate federal government agency access to this information for the sole purpose of audit.

RELEASE OF INFORMATION FOR THE EARLY INTERVENTION PROGRAM If my child is evaluated for or participates in the New York State Early Intervention Program, I give permission to the social services district and New York State to share my childs Medicaid eligibility information with my county or municipal Early Intervention Program for the purpose of billing Medicaid.

CHILD/TEEN HEALTH PROGRAM I understand that if my child is on Medicaid, he or she can get comprehensive primary and preventive care, including all necessary treatment through the Child/Teen Health Program. I can get more information on this program from the social services district.

MEDICARE I authorize payments under Medicare (Part B of Title XVIII, Supplementary Medical Insurance Program) to be made directly to physicians and medical suppliers on any future unpaid bills for medical and other health services furnished to me while I am eligible for Medicaid.

REIMBURSEMENT OF MEDICAL EXPENSES

MEDICAID You have a right as part of your Medicaid application, or within two years from the date of your application, to request reimbursement of expenses you paid for covered medical care, services and supplies received during the three-month period prior to the month of your application. After the date of your application, reimbursement of covered medical care, services and supplies will only be available if obtained from Medicaid-enrolled providers.

ASSIGNMENT OF INSURANCE/OTHER BENEFITS AND DIRECT PAYMENT For Public Assistance and Medicaid, I agree to file any claims for health or accident insurance benefits, and to pursue any personal injury claims or any other resources to which I may be entitled, and do hereby assign any such resources to the social services district to whom this application is made. In addition, I will assist in making any assigned benefits available to the social services district to whom this application is made. I authorize payments owed to me or members of my household for health or accident insurance benefits to be made directly to the appropriate social services district for medical and other health services furnished while we are eligible for Medicaid.

MEDICAID RECOVERIES Upon receipt of Medicaid, a lien may be filed and a recovery may be made against your real property under certain circumstances if you are in a medical institution and not expected to return home. MA paid on your behalf may be recovered from persons who had legal responsibility for your support at the time medical services were obtained. MA may also recover the cost of services and premiums incorrectly paid. I understand that effective April 1, 2014, if I get Medicaid through New York State of Health:

No lien will be placed on my real property prior to my death. Recovery from assets in my estate upon my death is limited to the amount Medicaid paid for the cost of nursing home care, home and community-based services, and related

hospital and prescription drug services received on or after my 55th birthday.


PUBLIC ASSISTANCE RECOVERIES Public Assistance (PA) you receive for yourself and for persons for whom you are legally responsible to support is recoverable from property or money you possess or may acquire. You may be required, as a condition of receiving PA, to execute a deed or mortgage of real property you own. Your tax refunds and portions of lottery winnings may be taken to repay your debt for PA.

AUTHORIZATION TO REPAY PUBLIC ASSISTANCE BENEFITS FROM RETROACTIVE SUPPLEMENTAL SECURITY INCOME I authorize the Commissioner of the Social Security Administration (SSA) to use my first payment of Supplemental Security Income (SSI); i.e. my retroactive SSI payment) to reimburse the local social services district (SSD) for Public Assistance (PA) the SSD pays me from State or local funds while SSA decides if I am eligible for SSI. SSA will not reimburse the SSD for PA that was paid using any federal funds. I will be bound by this authorization only if the State gives notice to SSA that I and an SSD representative have signed it. The State must give notice within 30 calendar days of matching my SSI record with my State record. SSA will not accept it after 30 calendar days. Instead, SSA will send me my retroactive SSI payment under SSA rules. Only my first payment of SSI can be used. If my first payment is larger than the amount owed to the SSD, SSA will send the rest to me under its rules. SSA can reimburse the SSD in two situations:

(1) It will repay the SSD if I apply for SSI and SSA finds me eligible. (2) It will repay the SSD if my SSI benefits are reinstated after termination or suspension.

SSA will only reimburse the SSD for PA it paid me during the time I am waiting for an SSA determination of eligibility. This is called interim assistance. The period begins: 1) with the first month I become eligible for payment of SSI benefits; or 2) on the first day I am reinstated after my SSI was suspended or terminated. The period includes the month SSI payments actually begin. If the SSD cannot stop my last PA payment, the period ends the next month. No later than 10 days after SSA reimburses the SSD, the SSD must send me a notice telling me the amount of interim assistance paid. The notice will also tell me that SSA will send me a letter telling me how any remaining SSI money owed to me will be sent by SSA and that, if I do not agree with a state decision, how I can appeal the decision to the state. Under its rules, SSA may use the date I sign this authorization as the date I first become eligible for SSI. It will do this only if I apply for SSI within the next 60 days. This authorization applies to any SSI application or appeal I now have pending before SSA. This authorization terminates if my SSI case is completely decided. It terminates when SSA first pays me. The State and I can also agree to terminate the authorization. I must sign a new authorization consistent with NYS rules if I reapply for SSI after this authorization terminates, or if I file a new SSI claim while I have an SSI application or appeal pending. I will be given an opportunity for a fair hearing if I disagree with a decision the SSD made about reimbursement. I received a copy of the pamphlet called What You should Know About Social Services Programs. I understand what it says about interim assistance.

SUPPORT Applying for or receiving Family Assistance (FA), Safety Net Assistance (SNA) or Title IV-E foster care operates as an assignment to the State and the social services district of any rights to support from any other person that the applicant or recipient may have in his or her own right or on behalf of any other family member for whom the applicant or recipient is applying for, or receiving, assistance (Social Services Law, Sections 158 and 348). This assignment is limited in certain situations. Other sections of this application contain additional assignments.

ASSIGNMENT OF SUPPORT RIGHTS I assign to the state and social services district any rights I have to support from persons having legal responsibility for my support and any rights I have to support on behalf of any family member for whom I am applying for or receiving assistance. Where applying for or receiving Family Assistance or Safety Net Assistance, my assignment of support rights is limited to support which accrues during the period that I and/or any family member receives assistance. However, any support rights that I assigned to the state on behalf of myself or any family member prior to October 1, 2009, continue to be assigned to the state.


HOME ENERGY ASSISTANCE PROGRAM I understand that by signing this application/certification, I consent to any investigation to verify or confirm the information I have given and other investigation by any authorized government agency in connection with Home Energy Assistance Program (HEAP) benefits. I also consent to allow the information provided on this application to be used in referrals to available weatherization assistance programs and my utility companys low income programs. I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to the New York State Office of Temporary and Disability Assistance, the local social services district and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program performance measurement.

SEXUAL ASSAULT INFORMATION If you are a victim of sexual assault, you have the right to request referral information from the social services district. If you request referral information, the social services district must provide you with the addresses and phone numbers of any: 1) local hospitals offering sexual assault forensic examiner services certified by the NYS Department of Health; 2) local rape crisis centers; and 3) local advocacy, counseling, and hotline services appropriate for victims of sexual assault. In addition, the social services district must provide you with the NYS Hotline for Sexual Assault and Domestic Violence numbers: (800) 942-6906 and (800) 818-0656 (TTY).

CERTIFICATION FOR CHILD CARE ASSISTANCE If I am applying for Child Care Assistance, I certify that my familys income does not exceed 85 percent of the State median income for a family of the same size, and my family resources do not exceed $1,000,000.

I Consent to Withdraw My Application For: Public Assistance (PA) Child Care in lieu of PA Supplemental Nutrition Assistance Program (SNAP) Medicaid and SNAP Medicaid and PA Services, including Foster Care Child Care Assistance Emergency Assistance Only I understand that I may reapply at any time. APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE DATE SIGNED x

I have read and understand the notices above. I understand and agree to the assignments, authorizations and consents above. I swear and/or affirm under the penalties of perjury that the information I have given or will give to the social services district is complete and correct.

APPLICANT SIGNATURE x

DATE SIGNED SPOUSE OR PROTECTIVE REPRESENTATIVE SIGNATURE x

DATE SIGNED

AUTHORIZED REPRESENTATIVE SIGNATURE x

DATE SIGNED

If you are not registered to vote where you live now, would you like to apply to register here today?

Important!Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.

YESNO because I choose not to register OR

I am already registered at my current address OR

I asked for and received a mail registration form

If you checked YES, please complete the VOTER REGISTRATION APPLICATION below

If you do not check any box, you will be considered to have decided not to register to vote

at this time.Informacin en espaol: si le interesa obtener este formulario en espaol, llame al 1-800-367-8683

:,: 1-800-367-8683

: 1-800-367-8683 .

1-800-367-8683

Signature Date

Please Print Name

/ /

Are you a U.S. citizen?

If you answered NO, do not complete this form

Will you be 18 years old on or before election day?

If you answered NO, do not complete this form

unless you will be 18 by the end of the year

YES NO YES NO

For Board Use Only

Last Name First Name Middle Initial Suffix

Address where you live (do not give P.O. box) Apt. No. City/Town/Village Zip Code County

Address where you get your mail (if different than above) P.O. Box, Star Route, etc. Post Office Zip Code

Date of Birth Sex Telephone (optional) Email (optional)

The last year you voted Your address was (give house number, street and city)

In county/state Under the name (if different from your name now)

M F

ID Number (Check the applicable box and provide your number)

New York State DMV number

Last four digits of your Social Security number

I do not have a New York State DMV or Social Security number

Affidavit: I swear or affirm that

I am a citizen of the United States.

I will have lived in the county, city or village for at least 30 days before the election.

I will meet all requirements to register to vote in New York State.

This is my signature or mark on the line below.

The above information is true, I understand that if it is not true, I can be convicted and fined up to $5,000 and/or jailed for up to four years.

Signature or Mark in ink Date

/ /

NYS Agency-Based Voter Registration Form

VOTER REGISTRATION APPLICATION (instructions on back) Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink Yes, I would like to be an Election Day worker

Last Name

(Optional) Register to donate your organs and tissues

First Name

Address

Birth Date

Middle Initial Suffix

City/Town/Village Apt Number Zip Code

By signing below, you certify that you are:

18 years of age or older

Consent to donate all of your organs and tissues for transplantation, research, or both;

Authorizing the Board of Elections to provide your name and identifying information to DOH for enrollment in the Registry;

And authorizing DOH to allow access to this information to federally regulated organ procurement organizations and NYS-licensed tissue and eye banks and hospitals upon your death.

Signature Date

/ /

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3

4

5

6

10

11

2

7 8

9

12

Sex

Eye Color Height

M F

Ft. In.

Rev. 2

/2015

Democratic partyRepublican partyConservative partyGreen partyWorking Families party

Independence partyWomens Equality partyReform partyOther

Political Party

I wish to enroll in a political party

I do not wish to enroll in a political party

No party

Qualifications for Registration

You Can Use This Form To: register to vote in New York State; change your name and/or address, if there is a change since you last voted; enroll in a political party or change your enrollment.

To Register You Must: be a U.S. citizen; be 18 years old by December 31 of the year in which you file this form (note: You must be 18 years old by the date of the general, primary, or other election in which you want to vote.); be a resident of the County, or of the City of New York at least 30 days before an election; not be in jail or on parole for a felony conviction; and not claim the right to vote elsewhere.

Important!

If you believe that someone has interfered with your right to register orto decline to register to vote, your right to privacy in deciding whether toregister or in applying to register to vote, or your right to choose your ownpolitical party or other political preference, you may file a complaint with:

NYS Board of Elections40 North Pearl St, Suite 5Albany, NY 12207-2729

Telephone: 1-800-469-6872;TDD/TTY users contact the New York State Relay at 711;

or visit our web site - www.elections.ny.gov

Your decision to register will remain confidential and will be used only forvoter registration purposes. Anyone not choosing to register to vote and/or information regarding the office to which the application was submittedwill remain confidential, to be used only for voter registration purposes.

Verifying your identity

We will try to check your identity before Election Day, through the DMV number (drivers license number or non-driver IDnumber), or the last four digits of your social security number, which you will fill in Box 9.

If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement,paycheck, government check or some other government document that shows your name and address. You may include a copy of one of those types of ID with this form.

If we are unable to verify your ide

new york state application for certain ...otda.ny.gov/programs/applications/2921.pdfcitizenship...

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